Guide
Medical Charting
Charting is the act of writing in the health record. In Canadian hospitals nurses say 'chart it.' Physicians more often say 'the note.' Both mean the same legal job: a timed, attributable account of what you knew and what you did.
What charting means in Canada
The health record is a communication tool, a memory, and evidence. Provincial colleges (physicians, NPs, nurses) all require timely, accurate, attributable documentation. PIPEDA and provincial health-privacy statutes (PHIPA in Ontario, similar acts elsewhere) govern who may see it. CMPA and CNPS both treat the chart as the story you will have to defend.
Charting is not billing. A complete note may support a fee code; stuffing the note to justify a code is still a documentation problem. Charting is also not a message thread. If the decision happened in a hallway, it still needs a timed entry.
- Who: name and designation, or an EMR login that maps to you.
- When: date and time of the event, and of the entry if they differ.
- What you observed, what the patient said, what you did.
- What you notified, and what the response was.
- Plan the next person can execute.
Fictional patients
Every example on this page uses made-up names and findings. They are teaching material. They are not a substitute for college standards, employer policy, or your own clinical judgment. Review every generated note before it enters the chart.
Paper, hybrid, and EMR
Paper charts still exist in parts of Canadian practice: long-term care, some rural EDs, downtime binders. Black or blue ink. Errors get a single line through, initial, date — not white-out, not a scribble. Late pages get labelled. The downtime binder has to be entered into the EMR when the system is back, as a late entry, not as if you typed it at 03:00.
EMRs add an audit trail. That is useful and unforgiving. Copy-forward, copy-paste, and 'carry forward exam' create a record of an examination you may not have done today. Smart phrases are fine if you edit them. A generated draft is fine if you read it. Signing is the clinical act.
| Medium | Do | Do not |
|---|---|---|
| Paper | Timed entries, legible, line-through corrections, original ink | Backdate, squeeze text into margins to hide sequence, remove pages |
| EMR | Sign, use late-entry labels, correct with addenda | Edit a signed note silently, copy last week's belly exam, share logins |
| Hybrid / downtime | Chart on paper in real time, transcribe as late entries later | Wait until the system is up to remember the 02:00 hypotensive episode |
Sample structure of a timed entry
Chart entry
Date / time of event: Date / time of entry (if different): Late entry: yes / no Author / designation / location: Patient identifiers confirmed: Context (why you are writing): Findings / patient report: Actions taken (including who you notified): Response / current status: Plan / pending: Signature / login:
Physicians often drop this into SOAP. Nurses often use narrative, DAR, or flowsheets plus a note. The structure above still holds: time, findings, action, response, plan. If your EMR splits vitals onto a flowsheet, do not pretend the flowsheet is a substitute for the notification you made to the MRP.
Late entries and addenda
A late entry is an honest label. Write the time you are writing, the time the care happened, and why the entry is late (code, another unstable patient, downtime, you were at the bedside). Never change the clock to make the note look contemporaneous. Never overwrite a signed note to tidy the story; add an addendum.
If a fact was wrong, say so. 'Addendum 2026-08-28 18:10: potassium reported as 2.4 at 16:40 was a mis-draw; repeat on a free-flowing sample is 3.6. MRP notified. Furosemide restarted.' Leaving the original error visible, with the correction beside it, is the point of an audit trail.
Example 1 — same-shift nursing entry
Medicine ward, contemporaneous
54-year-old woman, Halifax. 14:20. Fictional.
2026-08-28 14:20 RN [name], 5-Medicine, Rm 512. Called to room by family. Patient sitting at edge of bed, diaphoretic, saying "the room is spinning." BP 88/56, HR 110, RR 22, SpO2 95% RA, T 36.7. Alert, oriented to place. Abdominal dressing dry. Last pain med: hydromorphone 0.4 mg IV at 13:10. Actions: assisted back to bed, 250 mL bolus per protocol, held next hydromorphone, MRP paged at 14:22. Charge RN aware. 14:35 MRP at bedside. BP 102/64 after bolus. Orders: CBC, lytes, ECG, hold opioid, RTW if SBP <90. Patient now sitting up, dizziness improved. Plan: q15 min vitals x 1 h, then q1h x 4. Family updated.
Example 2 — physician late entry
MRP, labelled late entry
Same patient, Halifax. Written 17:05 for 14:35 review. Fictional.
Late entry — written 2026-08-28 17:05 for assessment at 14:35. Delay: second hypotensive patient on the ward, then family meeting in 508. Called by RN re: dizziness and BP 88/56 in 512, post-op day 2 laparoscopic hemicolectomy. At bedside 14:35: awake, no peritoneal signs, dressing dry, JVP not elevated, chest clear, calves soft. Post-bolus BP 102/64, HR 96. ECG NSR, no ischemic change. Differential: opioid + hypovolemia; bleed less likely clinically but not excluded. Orders as above. Hb 108 (was 112 morning). Repeat CBC 18:00. Discussed with patient: expected to improve with fluids and holding opioid; ED/OR if recurrent hypotension, increasing pain, or syncope. [signature, designation]
Example 3 — learner note, co-signed
Clerk with staff addendum
Family medicine teaching unit, Ottawa. Fictional.
2026-08-28 10:40 Clinical clerk [name], supervised. S: 8-year-old, two days of watery diarrhea, no blood, drinking well, wet diapers (still in pull-ups at night). Immunizations per CPP. No travel. Daycare. O: T 37.2, HR 96, moist mucous membranes, abdomen soft, no rebound. A/P: Acute gastroenteritis, no dehydration today. Oral fluids, return if no urine for 8 h, blood in stool, or lethargy. Note written for daycare. Staff addendum (Dr. [name], 10:55): Agree. Exam as above, performed with clerk. No antibiotics. CPP unchanged. Signed.
Habits that wreck the record
- Charting after you have already gone home, without a late-entry label.
- Copy-forward physical exams.
- Documenting a plan you discussed in the hallway and never entered as an order.
- Using another person's login, or signing a generated note you have not read.
- Writing 'incident report completed' as a substitute for the clinical facts (follow your site policy; the health record still needs the assessment and actions).
- Backdating paper notes so the sequence looks cleaner than it was.
Draft the entry, then own the time stamp
Scribeberry listens to the encounter, or takes dictation, and drafts a timed note in your template. You still set late-entry labels and sign. Edit, then Smart Push into Accuro, OSCAR, Jane, or any web EMR. Pro is $99/month after the free trial.
Frequently asked questions
What is medical charting?
Charting is documenting in the health record: a timed, signed account of findings, actions, and plans. In Canadian nursing and medicine it is a college requirement and the record CMPA or CNPS will be looking at if care is later questioned.
How should I write a late entry?
Label it 'late entry,' write the time you are writing and the time the care happened, and say why it is late. Do not change the clock or overwrite a signed note. Use an addendum to correct a fact that was wrong.
Is EMR charting different from paper?
The clinical duty is the same. EMRs add audit trails, copy-forward risk, and downtime procedures. Paper still needs legible timed entries and line-through corrections. Hybrid sites transcribe paper downtime notes into the EMR as late entries.
Does Scribeberry chart for me?
Scribeberry drafts the note from the visit or from dictation. You review, correct, label late entries if needed, and sign. The login that signs is still the author of record.
Templates
